Good Journalist Hunting, Part 2: Drugs, Sex, and American Healthcare

Background

In Part 1, I conveyed my experience in Target Corporation's stockroom to explain Amazon and Costco's success and said I'd discuss insurance companies and opioids in a subsequent post. 

The War on Drugs Results from Government's Desire to Monopolize Revenue Streams

Fewer than 0.06% of Americans between 15 and 64 years died from any kind of drug overdose in 2017. Why, then, are U.S. politicians so enamored with the drug war and opioids in particular? 

If you're a Chris Rock fan, you already know the answer. 

We got a horrible drug policy... The government always says drugs are illegal because they're bad for you and they're trying to protect society... [but] the government doesn't [care] about your safety... They don't want you to use your drugs, they want you to use their drugs... So every night, you see a drug commercial... trying to get you hooked on legal [stuff]... 

The reason cocaine and weed are illegal in America [has nothing] to do with your safety. The reason cocaine and weed are illegal in America is because the best cocaine and weed aren't made in America. If they made the good [stuff] here, there'd be a "Cocaine and Weed" restaurant on every corner [like Starbucks]... The government will never legalize drugs in America... because the government makes way too much money putting [black people] in jail. [Never Scared (2004)]

What you may not realize, however, is why the government is so keen to protect its own pharma revenue stream. 

Simply put, it costs a lot of money to develop new drugs. According to Bill Bryson in The Body (2019), on average, a billion dollars invested will get you one-third of a new drug, not even a complete one. 

Innovation within such a front-loaded system generally means only "Big Pharma" can participate, and research focuses on chronic illnesses like cancer and mental health issues--not life-saving new antibiotics, which work too quickly to generate recurring revenue. [Andrew Lo's Adaptive Markets (2017) proposes better ways of funding pharma R&D, but his ideas haven't caught on.]

America's funding paradigm incentivizes unnecessary diagnoses of mental health issues, autism, and other long-term conditions; worse yet, attaching the imprimatur of science to greed reduces the credibility of experts as well as academics.

Let's talk about how I found myself in a psychiatrist's office playing word association games at a rate of 300 to 400 dollars per hour. I've had weak ankles since a teenager, and after another swollen twist, I mentioned my despondence. My doctor, hearing Pavlovian bells of negligence, asked if I wanted to be referred to a psychiatrist. Having more free time due to an inability to play basketball, I agreed. Under the ACA, each state may create its own "competitive" marketplace, and mine is called "Covered California." Members can choose from platinum, gold, silver, or bronze plans, but the older you are, the more prohibitive the costs of anything above bare-bones bronze. In the beginning, insurers tried excluding mental health coverage to offer better cost-benefit propositions or more than de facto catastrophic coverage.   

Unfortunately, California's state legislature nixed the mental health and substance abuse opt-out, which it could do because once again, states dictate the terms and conditions of insurance coverage on state exchanges, not the federal government. (Incredibly, inclusive mental health coverage is more common than useful dental coverage, a distortion caused by pharma R&D costs being subsidized through insurance reimbursements, plus government's intent to delegate mental health and addiction issues to Big Pharma and religious entities rather than asylums, prisons, or clinics.)

Had insurance companies capped physical rehabilitation treatments to twice per month or not covered epidurals during childbirth, governmental intervention would be welcomed, but almost all medical coverage categories are general, figuring doctors should determine treatment, not legislators. Here, national legislators devised a healthcare program covering all Americans at reasonable prices, only to see courts and state legislators whack insurer flexibility and federal enforcement, thus reducing cost-effective options and oversight. 

A dysfunctional dynamic within government increases complexity and the likelihood of divided realities, especially when few Americans understand the law; conveniently, such ignorance leads voters to blame faraway Congress instead of nearby state and local politicians.

I believe that today, the average person is overwhelmed by the complexity of life because it got more complicated... I barely know an adult who isn’t on some kind of drug, either prescribed or otherwise, to deal with anxiety. -- Scott Adams, on "digital disease" (2018)

The general population doesn't know what's happening, and it doesn't even know that it doesn't know. One result is a kind of alienation from institutions. People feel that nothing works for them. -- Noam Chomsky (1993)

Yet, both sides, even their extremists, reflect one of three crystal-clear images: 

1) frustration with well-intentioned government programs no longer resembling their original conception as they trickle down to local levels and multiple special interests; and 

2) a sincere belief that more centralized (aka national) governance will reduce multi-layered bureaucracy as well as local resistance to implementation and change; or

3) a sincere belief less government and a more direct relationship between buyer and recipient will improve accountability.

All three choices are correct and also equally wrong. Whether a program works depends on the individuals administering it and incentives for questioning orthodoxy, not whether the program is corporate or governmental. It may be true some governments are inept at hiring, but so are many corporations (e.g., Enron, WeWork, Theranos, and Wirecard). If multi-national corporations have an advantage, it is mainly because they can hire non-citizens, meaning their talent pool is not only global, but able to gauge workers' skills at lower wages before bringing them onshore. (Government unions, especially teachers and police, don't help, but that's another matter.) 

Additionally, the lines demarcating private and public healthcare are often so blurry, they cannot be found. Take the Covered California website. It's possible the state created the website itself or the contractor who won the RFP (by bidding the lowest) hired only American citizens or onshore workers, but once up, de-bugging and security likely went offshore. Either way, I had to visit a private benefits office in person to show identification, because the state's website refused to accept my license or passport uploads. (Side note: economic data is easily manipulated; for instance, if the government's deficiencies create private sector "clean up" jobs, such jobs are given the same weight as meaningful jobs in the unemployment numbers.) 

Once registered and referred by my primary care physician to a psychiatrist, I drove to a private office complex, walked upstairs to a private office, waited about 10 minutes, and was shown into a lightly furnished room. The psychiatrist asked me a few questions, then began a modified version of the Rorschach test, where he displayed words on index cards and prompted for associations. If he showed you the word, "police," you could say "blue" or "Black Lives Matter" or "law" and so forth. After about 30 minutes of this ridiculous game, he decided I was bipolar and prescribed lithium and follow-up sessions. If I remember correctly, I attended two more sessions, which were similar, then stopped. The sessions, which my insurance paid, cost about 1,000 dollars. No solo practitioner in the legal field could ever get away with such lucrative billing for similar levels of work, but most independent lawyers do not have an insurance company paying their bills. The lesson? Insurance coverage raises prices with no guarantee of competent service, regardless of whether governmental or private actors are involved. Furthermore, inserting a third party between buyers and sellers increases risks of corruption, especially if the category of reimbursable services is ambiguous. 

Governments Must Be Allowed to Successfully Compete against Mafia Influence

Besides insurance, why are legal drugs and the process for obtaining them so expensive? First, you have to understand why governments exist. Government's primary function is to create, whether directly or indirectly, better alternatives to the informal economy while allowing reasonable inflation. Without inflation, debt becomes exquisitely burdensome for borrowers; and without debt, most legitimate businesses could not have been created or could not have survived economic cycles. (Amazon and Walmart are turning economic theories on their head, but both are inherently multi-faceted and trans-national, meaning they can accept lower profit margins and pass along cost savings by targeting billions of global buyers and sellers.) When considering the billions of dollars of banking loans to major pharma corporations, every illegal drug deal harms the flywheel of pharma R&D by reducing insurance reimbursements as well as healthcare premiums, making it harder for operators to pay back debt or to set up new labs at hospitals, university research facilities, or Merck and Co. headquarters. 

Now imagine an empty lot fifty miles from your house. 

From Sabrina (1954): 

Linus Larrabee: What’s money got to do with it? If making money were all there were to business, it'd hardly be worthwhile going to the office. Money is a by-product. 

David: What’s the main objective? Power? 

Linus: Agh! That’s become a dirty word. 

David: Well then, what’s the urge? You’re going into plastics now. What will that prove? 

Linus: Prove? Nothing much. A new product has been found, something of use to the world. So, a new industry moves into an undeveloped area. Factories go up, machines are brought in, a harbor is dug and you’re in business. It’s purely coincidental of course that people who've never seen a dime before suddenly have a dollar. And barefooted kids wear shoes and have their teeth fixed and their faces washed. What’s wrong with a kind of an urge that gives people libraries, hospitals, baseball diamonds and movies on a Saturday night?

If the mafia buys the lot instead of a mall, office, or factory developer, the city will not only receive less tax revenue, but will likely see its police force outgunned and outwitted, making neighborhoods less attractive to families and PhDs. More importantly, a mafia-influenced city--where violence exacts efficient payment and coercion--attracts different kinds of businesses and thus unreliable accounting as well as diminished transparency. Whereas most businesses seek to grow through superior service or products, the mafia grows as a way to evade taxation and to launder money.

In the EU, where the "Las Vegas" development model is being used to incentivize legitimacy, several blocks in Eastern Europe (aka former Soviet Union) have more dim-lighted casinos, wagering rooms, and upscale bars than Starbucks and McDonald's. In the United States, after "obscenity" charges became passé, content-neutral "time, manner, and place" restrictions required strip clubs, night clubs, hookah lounges, and other drug dealer hangouts to be away from schools, suburban moms, and anyone else with an 11 o'clock bedtime. 

Despite attempts at reasonable regulation, our ever-increasing levels of police funding and mafia growth--both of which reduce fertile ground otherwise able to foster economic diversity--indicate the balance of regulation has failed. 

Lawyers, Judges, Police, Politicians, and Teachers Have Used Governmental Influence to Create Jobs but not Meaningful Economic Alternatives, Allowing Mafias and Nepotism to Prosper 

Somehow, laws designed to give politicians and police greater ability to shape communities have caused the mafia and informal economic actors to become more respected. Such a result is only possible if government has misused its powers to create an antiseptic or equivalent existence, rendering the mafia the more interesting one. This anti-hero script explains the tragedy of Western governments, which have delegated social services to religious institutions, especially the Catholic Church; divided themselves by litmus tests of abortion and death penalty rights; and promoted separate and unequal compensation and disciplinary terms favoring existing employees and fellow churchgoers, with the occasional minority highlighted to mislead taxpayers, results be damned. 

In 2008-09 California’s [government] teachers were predominantly white (70.1%) and female (72.4%), quite a different look from the student population that was 51.4% male and had major ethnic categories of 49.0% Hispanic, 27.9% white, 8.4% Asian, and 7.3% African-American.

Setting aside global tax reform, you'd think a decent education would be the antidote, and it's not as if American K-12 education lacks money--the California teachers' pension fund alone has 242 billion dollars--so the absence of an informed public must be attributed to journalistic abdication and institutional corruption. 

In fact, American education is so terrible at producing competent voters, few adults realize state constitutions exist or that only governmental activity falls under the 1st Amendment. 

The Free Speech Clause prohibits only governmental abridgment of speech. The Free Speech Clause does not prohibit private abridgment of speech. - Supreme Court Justice Gorsuch, Manhattan Community Access Corp. v. Halleck (2019)

(I count myself as one of America's neglected--when I graduated law school, I didn't know about state constitutions, which typically extend rights beyond the federal Constitution, or even the location of the local courthouse.) 

In Western countries where governments haven't ceded education and social welfare to the Catholic Church and other "nonprofits," they, too, have failed to create the appropriate balance between regulation and opportunity. For example, according to journalist Stig Abell, Britain's NHS is the "fifth largest employer in the world." Mr. Abell's pride in his country's subsidized healthcare system excludes important details: when the NHS was created, research assumed shorter lifespans for most citizens, as well as higher birthrates to support tax transfers into a national healthcare system. If America has a military-industrial complex, then Britain has a healthcare-and-pension complex, and both require so much debt to occupy their economic spaces, efficiency and accountability by any means necessary look increasingly attractive to voters. (Meanwhile, if one enters a mafia-owned strip club or massage parlour and pays cash, one can usually get service without queuing or being assigned to a waiting list.) 

And so, however one looks at Western healthcare and secondary education, failure looms, and exceedingly complex failures are exactly why most Western politicians can focus on opioids and other outliers without fearing logical retort or upsetting the status quo. Worst of all, the honest politician who tries to re-enact Mr. Smith Goes to Washington (1939) on the local level must contend with other cities and states of lesser moral fiber capturing lobbying and other dollars on the sound principle that if they do not accept inertia's largess, someone of even lesser moral fiber will. Given such circumstances, one can be forgiven for elevating a mafia don or high-level confidential informant above a politician or lawyer who makes promises s/he cannot keep without becoming a banker's whore. 

The creatures outside looked from pig to man, and from man to pig, and from pig to man again; but already it was impossible to say which was which. -- George Orwell, Animal Farm (1945) 

The Path of Least Resistance

Now that you better understand the miasmatic cauldron of corruption and general depravity through the lessons of Western drugs, healthcare, and education, you can vote more responsibly. Will your heightened civics knowledge make a difference when the only consistently good Western politicians are Scotland's retired Gordon Brown, Australia's retired Paul Keating, and Czechia's dead Vaclav Havel? Probably not, but democratic governments were never meant to be better than the citizens within them. In fact, though democracies tend be more transparent, transparency combined with complexity spanning multiple levels of governance is no guarantee of clarity. Thus, despite much progress, we have returned to where we were centuries ago, mucking about, unclear which direction to go, side-eying our neighbors, and praying a pandemic doesn't wipe us out. If this be progress, I'll take the whore, and you can keep the teachers, priests, politicians, lawyers, and made men. 

© Matthew Mehdi Rafat (2020) 

"Men will never be free until the last king is strangled with the entrails of the last Catholic priest." - attributed to Denis Diderot

Bonus: as Adam Gopnik, New Yorker (2017) explains, John F. Pfaff makes reasonable counterarguments regarding Chris Rock's statements above: 

"During the great wave of incarceration—generally thought to have begun around 1980, and cresting about three decades later—state prisons added something like a million inmates, with about “half that growth coming from locking up more people convicted of violence,” Pfaff calculates. Nonviolent drug offenses accounted for only around a fifth of the new incarcerations... [Emphasis mine.] 

So what makes for the madness of American incarceration? If it isn’t crazy drug laws or outrageous sentences or profit-seeking prison keepers, what is it? Pfaff has a simple explanation: it’s prosecutors. They are political creatures, who get political rewards for locking people up and almost unlimited power to do it." 

Bonus: Good Journalist Hunting, Part 1 is HERE. Part 3 is HERE. 

Healthcare in America: Symptom of Overall Decline

I just ordered a new hearing aid. I bought it from the same entity I pay health insurance to. Hospitals may be non-profit or for-profit, but the label isn't very helpful because any entity with salaries and overhead must focus on getting money or go bankrupt.

Americans are confused about "for-profit vs. non-profit" because they're not used to seeing actual sticker prices for healthcare services and because insurance has allowed diffusing ever-escalating costs. Such a system works only if more people are added to the same insurance pool each year, which gets trickier if true competition exists. 

On paper, a for-profit entity has more incentives than a non-profit to be efficient and better at preventative medicine, thereby lowering long-term costs. Yet, even that basic premise is questionable if a non-profit has leadership that rewards employees for efficiency and reducing the number of unnecessary third-party tests. The trick is getting the balance between efficiency and customer service right.

Why do other countries seem to handle healthcare better? Reasons might be counterintuitive or simple. For example, they could be dealing with a population that drives less because of better public transportation, which increases daily walking time and therefore decreases heart disease rates. Maybe people are less stressed because they have less debt or more free time. Perhaps fewer people engage in excessive drinking or prefer wine to beer. (Even the "wine vs. beer" factor requires more analysis because the main difference might be that most wine is more expensive than most beer, encouraging less consumption and therefore fewer negative health effects.) Is the climate extremely hot, encouraging more showers and therefore more cleanliness, reducing disease transmission? Or does a hotter climate make it harder to walk more, increasing health risks? 

The more we analyze complex problems, the more it becomes obvious that nothing can be fixed on a national level in any large country, and one reason smaller countries like Singapore are so successful is because they are smaller and can act locally and more quickly when problems arise. (Note: "democracy" isn't necessarily the answer to anything once you realize any system that encourages local solutions, accountability, and more humility works.)

Back to my hearing aid purchase. I've been severely hearing-impaired since birth. American health insurance doesn't fully cover hearing aids, even if medically necessary. Also, tax write-offs require such a high level of medical expenses, almost no one actually qualifies. (Meanwhile, a dollar spent on advertising creates an automatic, above-the-line deduction--the best kind of tax break.) I will be paying 1200 USD out-of-pocket for the most basic Oticon aid, labeled as "entry" level. I probably need two more functional aids costing 2600 USD each, but I tend to spend a lot of time alone (cue the chicken or the egg debate), and I'd rather use my money for more pleasurable experiences like eating out or even giving it to a friend who can pay off high-interest consumer debt.

Why do I share my experience with you? I want you to get a sense of why American healthcare is so problematic and why labels like "single payer" or "for-profit" don't help. When I made the appointment to purchase the new aid, I already had the benefit of a previous visit, where the audiologist explained the different options and price points to me. I was given a standard half-an-hour appointment, but I saw the system scheduled the next patient in 20 minutes, creating an incentive to minimize the time spent with me.

Not knowing about the 20 minute scheduling until my follow-up visit, I brought another aid I use as a back-up, which needed a simple tubing replacement. The audiologist looked at it and told me it's not common for Kaiser to work on an aid not purchased through its own service. She turned the aid over a few times and finally left for three minutes and returned with a tube.

A tube is just a piece of plastic attaching the earmold to the electronic aid that goes behind the ear, but if the five cent piece of plastic isn't replaced regularly, the expensive aid won't work optimally. Before Kaiser, I had a private audiologist, and it was standard procedure to clean or replace the tubing if requested. Unlike Kaiser, the private audiologist doesn't get an automatic stream of customers referred from the overall insurance pool, so it has incentives to treat customers well. It is a for-profit entity, while Kaiser Permanente is one of the nation's largest non-profit health plans. Before I go further, I want to say I like Kaiser. It has an integrated-care model, which is the future of healthcare--if we get it right.

Interestingly, the audiologist told me Kaiser's hearing aid unit was "for profit." I'm not a tax lawyer, and the idea of a non-profit entity with a for-profit subsidiary sounds odd, but it's possible the audiologist isn't a tax expert and mis-spoke. Later, I realized the audiologist's use of "for profit" might have been a way to subtly get out of performing a basic medical service. If you only have 20 minutes a patient, and if you don't need to attract new patients because they're part of an existing insurance network, why do extra work? What is the incentive to treat the patient as a whole person, regardless of whether your corporate structure is for-profit or non-profit?

Such problems aren't unique to healthcare. Even mid-sized law firms now require associates to charge 10 or 20 cents per copy, limiting copy machine use by requiring an electronic client billing code. In the past, firms would also charge an inflated flat rate to send faxes. As you might suspect, the incentive to nickel-and-dime clients in a for-profit system is high, which leads many people to advocate a non-profit system where the culture can, in theory, focus on seeing the person as a whole human being. Yet, here I was, in a non-profit entity, and the incentives clearly discouraged an audiologist from assisting me in a simple way. The lesson? Tax structures don't tell you anything about employees or their dedication. They don't tell you whether the employee is burned out or if she feels like a meaningless cog. They don't tell you if the employee wants to help you but is constrained by policies discouraging common sense.

A for-profit system might be better if it attracts the most ambitious, hard-working employees, especially if a non-profit system pays less or attracts burned-out employees. Indeed, even a non-profit system must manage patients efficiently, and software now handles day-to-day operations for most large entities, restricting flexibility and personal initiative. 

Remember going to a doctor's office and waiting for 20 to 30 minutes after your appointment time? What if that inefficiency allowed the doctor to listen to patients more and give everyone the benefit of more personal service? What if technology has sacrificed our ability to feel useful and to take care of people in ways that build lasting relationships? What if tolerating technological advances that limit personal flexibility but increase efficiency has seeped into other parts of American culture, limiting our ability to think long-term?

I don't know the answers to the above questions, but removing personal discretion from employees and increasing hurdles to long-term customer relationships aren't the solutions. To be fair, the audiologist did give me extra options that answered other questions I had. However, by the time she showed me a catalog with useful add-ons, I didn't know if she was genuinely trying to help me, or if she had a sales quota. 

Dealing with American healthcare is enough to make a diehard capitalist into a committed socialist. That should scare us all. 

Bonus: "Despite all the false positivity, I find Americans to be generally the most stressed out and unhappiest people on the planet. Despite all the resources, and all the money they have, they are sadder than people I know who can barely make ends meet in other countries, but still know how to live in the moment." -- Benny Lewis 

Satire: Healthcare Reform

Awesome post on healthcare reform here. My fav?

The government is incapable of running anything efficiently, and if allowed to offer a health care option, will run health care so efficiently that it will put private insurers out of business.

And I thought satire was dead.